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Modified ILOA Form

This document appears to be a form for assessing a patient's level of assistance needed to complete various mobility tasks, such as sitting up, standing, walking, and walking distance, at initial assessment and before discharge from therapy. Scores are given for each task and totaled. A grading guide is also referenced but not provided. The form collects information on the patient, location, date, assessor, and scores for tasks to chart their progress.

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Roger
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5K views1 page

Modified ILOA Form

This document appears to be a form for assessing a patient's level of assistance needed to complete various mobility tasks, such as sitting up, standing, walking, and walking distance, at initial assessment and before discharge from therapy. Scores are given for each task and totaled. A grading guide is also referenced but not provided. The form collects information on the patient, location, date, assessor, and scores for tasks to chart their progress.

Uploaded by

Roger
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Modified Iowa Level of Assistance Scale 1

Patient Name __________________________________________________________________

Group __________________________________________________________________

Location __________________________________________________________________

Rater __________________________________________________________________

Initial Assessment: (Date: ____/____/____)


Task Score
1. Supine to Sitting on the Edge of Bed
2. Sit to Stand
3. Negotiation of One Step
4. Walking
5. Walking Distance
6. Assistive Device Used
Total

Assessment Before Discharge: (Date: ____/____/____)


Task Score
1. Supine to Sitting on the Edge of Bed
2. Sit to Stand
3. Negotiation of One Step
4. Walking
5. Walking Distance
6. Assistive Device Used
Total
Grading Guide:

1
Kimmel, L., Elliott, J., Sayer, J., & Holland, A. (2015). Assessing the Reliability and Validity of a Physical
Therapy Functional Measurement Tool—the Modified Iowa Level of Assistance Scale—in Acute Hospital
Inpatients. Physical Therapy, 96(2), 176-182. doi: 10.2522/ptj.20140248

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